Mary Blankson, DNP, APRN, FNP-C
Chief Nursing Officer The Community Health Center Inc.
Middletown, Connecticut
Presenter Disclosures
No personal financial relationships with
commercial interests relevant to this presentation existed during the past 12
months.
FederallyQualifiedHealthCenters(FQHCs)¥ Na#on’slargestsafetynetse0ng¥ Locatedindesignatedhighneedcommuni#es¥ Caringfor24millionpa#entsannually¥ 93%servedarebelow200%poverty&35%uninsured
CHCProfile¥ Foundingyear:1972¥ Primarycarehubs:14;204sites¥ Annualbudget:$100m¥ Staff:1,000¥ Pa#ents/year:100,000(est.2017)¥ Special#es:onsitepsychiatry,podiatry,chiroprac#c¥ Specialtyaccessbye-Consultto15specialists
ElementsofModel¥ FullyIntegratedteamsanddata¥ Integra#onofkeypopula#onsintoprimarycare¥ Datadrivenperformance¥ “WhereverYouAre”approach
WeitzmanIns>tute¥ QIexperts;na#onalcoaches¥ ProjectECHO®—specialpopula#ons¥ FormalResearchandDevelopment¥ ClinicalWorkforceDevelopment
CHCLoca>onsinConnec>cut
• Chronicpainaffectsatleast116millionAmericansandcostsupto$635billioninmedicaltreatmentandlostproduc#vity1
• Majorityofpa#entswithpainseekcareinaprimarycarese0ng1
• PrimaryCareProvidersexpresslowknowledgeandconfidenceinpainmanagementandreceivelihlepainmanagementeduca#on2
• Opioidsareheavilyreliedonforpainmanagementinprimarycare
• Prescrip#onopioidoverdoseisamajorandgrowingpublichealthconcern
Chronic Pain in the US
Oxycodone Consumption (mg/capita) 1980-2013 International Narcotics Control Board, World Health
Organization
OpioidCrisis
Providers
AlleviateSuffering&ImproveQualityof
Life
IndustryTreatPain&
DevelopaMarket
Pa>ents
StrugglingwithChronicPain,Unrecognized/
UntreatedTrauma&ManywithPrior
HistoryofSubstanceUse
DisorderorotherBHComorbidi#es
• InsuranceCoverage• LackofAccesstoSpecialists• Transporta#onIssues• HealthLiteracy(Percep#onofpain,othermodali#es,lifestyle
modifica#on)• Changingguidelines• Andothers
Added Complexity
Pain patients are like beach balls at a concert…
ShaunLowe/iStockphoto.com
Supporting Primary Care Providers to Improve Pain Care
• Standards • E.H.R. Solutions • Data Tools • Telehealth • Learning and Collaboration • Oversight • Prevention & Treatment of Substance Use Disorder
hhp://diysolarpanelsv.com/free-clipart-support.html
Supporting Primary Care Providers to Improve Pain Care
• Standards • E.H.R. Solutions • Data Tools • Telehealth • Learning and Collaboration • Oversight • Prevention & Treatment of Substance Use Disorder
hhp://diysolarpanelsv.com/free-clipart-support.html
CHCI Standard Policy for Opioid Prescribing All patients receiving COT* must have
• Signed opioid agreement scanned and saved in the HER, Updated Yearly
• Random Drug screen at least once every 6 months • Follow up visit every 3 months (minimum) using pain
template and functional assessment • Review of State PMP • Behavioral Health co-management encouraged
Primary care providers should avoid: Rx > 90MME Opioids and benzodiazepines in combination
*COTdefinedasreceiptof90daysormoreofprescrip#onopioidanalgesicmedica#on
Stepwise Approach to Pain • Non-opioid treatments. Non-controlled medication. • Alternative Services
• Chiropractic care • Acupuncture • Physical Therapy • Nursing Support • Nutritional Support
• Behavioral Health Co-Management • Realistic goals and expectations: function vs. pain free
Supporting Primary Care Providers to Improve Pain Care
• Standards • E.H.R. Solutions • Data Tools • Telehealth • Learning and Collaboration • Oversight • Prevention & Treatment of Substance Use Disorder
hhp://diysolarpanelsv.com/free-clipart-support.html
CCustomizeEHRtoSupportQualityPainCare
Use an Opioid Agreement
Routine Drug Screens
• Frequent, but irregularly timed drug screens • Know how to correctly order urine screens from
your local lab • Capture all lab codes
• Know how to correctly interpret urine drug tests • Confirming Rx’d medication presence • Confirming Non-Rx’d medication
absence
Use State Prescription Monitoring Sites
Connec#cutPrescrip#onMonitoring&
Repor#ngSystem(CPMRS)
www.ctpmp.com
Supporting Primary Care Providers to Improve Pain Care
• Standards • E.H.R. Solutions
• Data Tools • Telehealth • Learning and Collaboration • Oversight • Prevention & Treatment of Substance Use Disorder
hhp://diysolarpanelsv.com/free-clipart-support.html
Use Data to Monitor: Dashboard
• % Panel on COT • Presence/absence of opioid agreements • Presence/absence of toxicology screening • Last Pain Assessment (template used—
includes functional assessment & risk mitigation)
• Last CTPMP check • Last BH encounter • Next BH encounter • BH provider
ProviderNames
Opioid Management Dashboard
Systems and Technology and Process Collaborative Care Dashboard
§ Planned Care in Behavioral Health § Delivery of Integrated Services
Rethinking the warm hand-off process: Proactive vs. Reactive
22
• Medical initiated warm hand-off and behavioral health initiated warm hand-off
• Staggered vs. consecutive visits – make our presence known
• Criteria:
• No BH services and PHQ above 15
• No BH services and BH Diagnosis
• No BH services and chronic pain patient
Supporting Primary Care Providers to Improve Pain Care
• Standards • E.H.R. Solutions • Data Tools • Telehealth • Learning and Collaboration • Oversight • Prevention & Treatment of Substance Use Disorder
hhp://diysolarpanelsv.com/free-clipart-support.html
TreatPainbyMovingKnowledge,NotPa>ents
Pain Management eConsult example
page2/2
Pain Management eConsult example (continued)
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Pain Management
Supporting Primary Care Providers to Improve Pain Care
• Standards • E.H.R. Solutions • Data Tools • Telehealth
• Learning and Collaboration • Oversight • Prevention & Treatment of Substance Use Disorder
hhp://diysolarpanelsv.com/free-clipart-support.html
Learning & Collaboration: Team Based Care • Empower staff to manage challenging
encounters • De-escalation Training
• Project ECHO CCM Didactics for RNs • Chronic Pain • Substance Use Disorder • MAT/Harm Reduction
• BH Groups as well as one-on-one • Performance Appraisal measures for all clinical
team members
Supporting Primary Care Providers to Improve Pain Care
• Standards • E.H.R. Solutions • Data Tools • Telehealth • Learning and Collaboration
• Oversight • Prevention & Treatment of Substance Use Disorder
hhp://diysolarpanelsv.com/free-clipart-support.html
Opioid Review CommitteeCommittee with oversight over opioid prescribing (sub-committee of Pharmacy & Therapeutics)
• Establish Formulary (Do Not Rx, 2nd Tier Review, etc.)
• High dose opioid oversight and review • 2nd level review/authorization • Review outlier providers (high pill counts, high MEQ,
dangerous combos) • Establish internal guidelines • Follow up directly with prescriber
Provider Specific Opioid Data Report (Pg. 1)
Provider Specific Opioid Data Report (Pg. 2)
Components of Targeted Chart Review • Has history, Physical Exam, and appropriate diagnostic imaging
testing been documented?
• Has an assessment of risk for substance abuse, misuse, or addiction been documented?
• Has a discussion of therapeutic harms and benefits of opioids been documented?
• Is there a current controlled substance agreement on file?
• Has a discussion of goals, expectations, risks, and alternatives been documented?
• Has the patient been screened for behavioral health comorbidities such as depression, anxiety, etc.?
Components of Targeted Chart Review • Has the patient had a visit at least once every three months in
which pain management was assessed and discussed and a treatment plan was documented?
• Has a functional assessment score been documented and reviewed at least once every three months?
• Is there documentation that the PMP database has been accesses and that there are no aberrancies?
• Is random toxicology screening performed at least twice yearly?
• For patients with a history of substance abuse, psychiatric issues, or serious aberrant behaviors, have more frequent toxicology screens been performed?
Components of Targeted Chart Review • Has a multi-modal treatment plan been developed,
implemented, and documented, including referrals to behavioral health for co-management along with additional referrals as appropriate to other specialists including but not limited to the following:
• Physical Therapy/Occupational Therapy
• Addiction Treatment
• Chiropractic Care
• Acupuncture
• Mindfulness
• Pain Management or Physical Medicine
Components of Targeted Chart Review • Is there documentation that the provider has asked about
adverse effects from opioid medications?
• Has the provider appropriately discontinued opioid medications in the following circumstances:
• Aberrant drug-related behavior
• Abuse
• Diversion
• Lack of progress toward goals
• Adverse reactions/effects from medication?
PostORC:ChronicOpioidPrescribingPrac>ces
PostORC:OpioidPrescribingPrac>cesin3MonthPeriod
Supporting Primary Care Providers to Improve Pain Care
• Standards • E.H.R. Solutions • Data Tools • Telehealth • Learning and Collaboration • Oversight • Prevention & Treatment of Substance Use
Disorder
hhp://diysolarpanelsv.com/free-clipart-support.html
The Opioid Crisis • Opioid Overdose deaths have quadrupled since 1999 and
account for roughly 63% of drug overdose deaths in the US in 20153
• Sharp increase between 2006-20153
• Increase in the supply and use of heroin
• Increase of mixing fentanyl into heroin supply
• Increase in deaths involving synthetic opioids without heroin
***The strongest risk factor for heroin use and dependence is misuse of or dependence on
prescription opioids***
Opioid Action Plan • Inclusion of all departments (clinical & non-clinical) • Interventions designed to:
• Enhance patient and community education • Improve Access (to MAT, ancillary care, etc.) • Engage community partners • Improve team support (standing orders, BH
groups, etc.) • Involve all care delivery sites (SBHCs, W.Y.A.,
Prenatal, etc.) • Measure/evaluate impact (short-term,
intermediate and long-term effects) • Share Successes and Best Practices
Opioid Action Plan
Opioid Action Plan • Policy Issues (CHC & State/National) • Narcan • EHR Updates (templates, documented patient ed, etc.) • Other providers: BH, Chiropractors, Dieticians • CCM • Prenatal • SBHC • W.Y.A. • HR • Leadership/Regional VPs • Communications
Conclusion and Next Steps • Chronic Disease Approach/Chronic Disease Support
• MI/SMG Opioids/Chronic Pain/Addiction • Planned Primary Care
• Planned Care Dashboard Alerts • Standing Orders • Streamlined Nursing Visits • Consider Studying Required Chiro prior to Opioid
Initiation • Address Behavioral Health Co-Management/Co-
Prescribing Responsibilities • Formal OAP Scorecard to Track Outcomes
Implications for the DNP • The possibilities are endless
BUT… • You have much responsibility
• Demonstrate Leadership • Focus on Change that Makes a REAL Difference • Innovate • Don’t Be Afraid to Think Too Small or Too Big • Measure, Measure, Measure • Celebrate Success & Failure • Listen to Your Mentors • Support Others Along the Way
Other Key Individuals • Margaret Flinter, PhD, APRN, FNP-BC, Sr. Vice
President & Clinical Director • Veena Channamsetty, MD, Chief Medical Officer of
CHCI • Daren Anderson, MD, Chief Quality Officer of CHCI and
Director of the Weitzman Institute (WI) • Tim Kearney, PhD, Chief of Behavioral Health of CHCI • Sheela Tummala, DDS, Chief Dental Officer • Nick Ciaburri, Director of Business Intelligence • Zachary Manville, Database Developer II • Tierney Giannotti, MPA, Quality Improvement Data
Analyst for CHCI & WI
References 1Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington (DC): National Academies Press (US); 2011. Available from: https://www.ncbi.nlm.nih.gov/books/NBK91497/ 2Anderson, D. R., Zlateva, I., Coman, E. N., Khatri, K., Tian, T., & Kerns, R. D. (2016). Improving pain care through implementation of the Stepped Care Model at a multisite community health center. Journal of Pain Research, 9, 1021–1029. 3Rudd, R.A., Seth, P., David, F., & Scholl, L. (2016). Increases in Drug and Opioid-Involved Overdose Deaths — United States, 2010–2015. MMWR, 65, 1445–1452. Dowell, D., Haegerich, T.M., Chou, R. (2016). CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR, 65:1–49.
QUESTIONS?
Contact:
Na#onalAdvisoryCouncilonNurseEduca#onandPrac#ce
Mary Blankson, DNP, APRN, FNP-C Chief Nursing Officer
Community Health Center Inc. 675 Main Street
Middletown, CT 06457 [email protected]